| RPT |
|
| DOB: <.Patient_Date_Of_Birth.> (<.Patient_Age.>)
| Gender: <.Patient_Gender.>
|
|<*Answer_7771*>
|
|
|Questions and Answers:
|
| 1. This questionnaire asks about experiences you may have had after a
|very stressful experience. Please indicate whether you had at least one
|Moral Injury Outcome Scale and Brief Inventory of Psychological Functioning (MIOS+B-IPF_V2)
|experience as described below that is currently distressing
|(select all that apply).
|
|<*Answer_7772*>
|
| MIOS
| 2. I blame myself.
| <*Answer_9284*>
| 3. I have lost faith in humanity.
| <*Answer_9285*>
|
| 4. People would hate me if they really knew me.
| <*Answer_9286*>
| 5. I have trouble seeing goodness in others.
| <*Answer_9287*>
| 6. People don't deserve second chances.
| <*Answer_9288*>
| 7. I am disgusted by what happened.
| <*Answer_9289*>
| 8. I feel like I don't deserve a good life.
| <*Answer_9290*>
| Date Given: <.Date_Given.>
| 9. I keep myself from having success.
| <*Answer_9291*>
| 10. I no longer believe there is a higher power.
| <*Answer_9292*>
| 11. I lost trust in others.
| <*Answer_9293*>
| 12. I am angry all the time.
| <*Answer_9294*>
| 13. I am not the good person I thought I was.
| <*Answer_9295*>
| Clinician: <.Staff_Ordered_By.>
| 14. I have lost pride in myself.
| <*Answer_9296*>
| 15. I cannot be honest with other people.
| <*Answer_9297*>
| B-IPF
| 16. For the following questions of the B-IPF assessment, reflect on
| how much this experience made it hard for you to function
| in each of the areas listed.
| <*Answer_9298*>
| 17. I had trouble in my romantic relationship with my spouse or
| Location: <.Location.>
| partner.
| <*Answer_9299*>
| 18. I had trouble in my relationship with my children.
| <*Answer_9300*>
| 19. I had trouble with my family relationships.
| <*Answer_9301*>
| 20. I had trouble with my friendships and socializing.
| <*Answer_9302*>
| 21. I had trouble at work.
| <*Answer_9303*>
|
| 22. I had trouble with my training and education.
| <*Answer_9304*>
| 23. I had trouble with day to day activities, such as doing household
| chores, running errands and managing my medical care.
| <*Answer_9305*>
|
|Information contained in this note is based on a self-report assessment
|and is not sufficient to use alone for diagnostic purposes. Assessment
|results should be verified for accuracy and used in conjunction with
|other diagnostic activities.
| Veteran: <.Patient_Name_Last_First.>
| SSN: <.Patient_SSN.>
|
